I’m annoyed at this term. Annoyed enough that I have to restart this blog. I heard for the first time about a week ago.

Apparently, defying the realities of human development, people are supposed to be the same at 13 as they were at 3 or will be at 33 or 73. When I first started working exclusively in gender, we used the term consolidation when referring to identity. Is his/her identity consolidated? I’ve come to believe this is the wrong frame and based in inaccurate explanations of human development.

For years I’ve railed against Erikson, who underpins American psychology and education, that we were all supposed to have achieve certain developmental goals before moving onto the next goal. It assumes a linearity that I do not believe exists for all of us. Erikson and Marcia’s ideas were limited by the times in which they lived.The world has changed in ways they could not have imagined.

We have inherited an essentialist belief that who you are at 3 or 5 is who you will stay. I remember hearing silly things like that in school. That people resolve identity crises and then their identity becomes fixed in stone. Like the binary in gender, some of us find ourselves wrapped snuggly in polarity like a cashmere sweater and for others it’s like wearing fiberglass.

Essentialism was a way to organize information back before we understood what we know now. Any individual is a complex system. What one is at the current time is their current state—this doesn’t mean that a person wasn’t who they were at an earlier time. They have grown and developed based on new experiences, new information.Who you are at 3 is 3-year old you and doesn’t necessarily predict much about 13-year-old you.

Many humans, who like to organize, categorize and control, like simple answers. The truth is, nature is complex. Life is nothing if not filled with diversity. We try to simplify. How we know how to relate to people is to determine what box they are in and then follow the rules. Those rules have changed over time, too. Men are like this, women likethis, blacks like this, whites like this, Asians like this. It’s culturally informed. It also has changed as we have grown.

Neuroscience shows us that the brain is constantly changing. There may be innate aspects, but experience overwhelms them. Learning matters. And not in the way that many people with a simplistic understand of nature versus nurture think.

So what does this have to do with the notion of “rapid onset gender dysphoria?” We assume that since a child hasn’t consistently behaved in gender conforming ways, that they can’t be who they say they are as an adolescent or a young adult.

As I said, when I was starting out we had this idea of “consolidated” gender identity. Gender was fixed and binary. The concern then was about older people transitioning–why were they suddenly showing up wanting surgery and hormones after having lived decades as the sex/gender they were assigned at birth? It was easy for providers to question and discredit the patients’ experience because it didn’t follow this essentialist thinking. The essentialist explanations–the person must be mentally ill–were the exact opposite of what was actually happening for many people. The assumption was if they were “truly transgender” they would have presented earlier. Generally, people are much more practical and much more complex.

The truth was, there were lots of reasons people didn’t present sooner for assistance transitioning. They had family obligations that were more important than their individual needs. They didn’t know that transitioning existed and they did the best they could to cope before they discovered there was help. People waited til their kids were grown, their parents were dead, that they had save all the money they thought they would need. That they finally could not live a lie anymore–they tried to make something work that could not work. That they retired and were finally free to be themselves.

Now we are using this same microscope to look at youth. So are there practical explanations for “rapid onset” youth? Probably. Without thinking very hard on this it’s become easier for youth to come out now–easier than ten years ago. Parents are likely more generous around cross gender play than they were ten years ago. Maybe what felt like lesbian or gay is better understood for the youth as male or female. As the youth becomes more sophisticated in their thinking, they have more complicated identities than they did when they were younger. That parents didn’t observe. Parents often do not see what they do not want to see. We know this about many issues. Parents explain things to themselves from the frames which work for them. Our children bring us new challenges to our thoughts and ideas.

And the bigger issue is that the lens we have is wrong. It isn’t a problem to newly identify an issue or aspects of one’s identity as we grow and change. How a person comes to their gender identity can be different for different people. No one size fits all no matter how much easier life would be if things were so binary–yes/no. gay/straight. male/female. Or American/other. Good guys/bad hombres. Our government wants simple. They don’t want science. They don’t want diversity. We know that’s off. Build a wall as a solution to a very complex problem.

Our understanding of gender is in it’s own adolescence at best. We have a long way to go as providers and as society. We actually don’t need to build walls to try to control people–that’s more reactionary fear-based ideology.

I’ll write more soon on regret and detransition and how I believe it fits in with these ideas. We’ve already, I think explained, the problems related to desistance language and the flawed studies that are used to support it. (like misusing gender non-conforming to mean transgender when they aren’t the same at all. they simply overlap)

We don’t have good information about detransition, retransition and regret. People are pointing to old studies. Once again this population is a small group within a small group so no good data and there is likely a reluctance on the part of some people to really tackle the issue. Sometimes the best place to find info really is the internet and not your friendly local gender therapist or primary care doc.

If I wait until this is where I want it to be I will never post it. So I will update this post. Maybe turn it into a page.

Our society is pretty reactive. For some, if medical transition is wrong for some people it must be wrong for everyone and if transition is right for some people it’s the only path we should advance for everyone with dysphoria. I’m a bigger fan of matching people up with the best intervention, doing genuine informed consent which would have a lot of I don’t knows included in it and then taking good care of them across their life span.

For the sake of clarity, since talking about regret can be misperceived as being anti-trans, I believe that hormonal and surgical transition is the best course for some people. I also believe I do not have a crystal ball that can tell exactly who will be happy or unhappy. For some people, while medical intervention will not make the dysphoria disappear it may improve the quality of their lives. I’m all for improving the quality of people’s lives and stopping the way in which we discard people and warehouse them in slums. I’m all for expanding definitions of gender expression for all ages of people. I get off topic at times…

Not all people who detransition regret transitioning by the way. For some people it was a developmental step or the only way to answer a question and discover that it wasn’t the best answer.

There are increasing numbers of blogs about regret and detransition. Some of them are enraging because they cite inaccurate statistics or take quotes from studies out of context or basically just make things up. Many point to an article in the English paper the Guardian as proof of the failures of transition. There is no published study to go with that article so no peer review no way to really look at the data. One of these days I will take that article apart i just need more time in the day. Anyhow sites that quote it are red flags if you are looking for factual information.

I wanted to point out a few sites that are valuable and even if I disagree with what is in them, there is a lot of useful information and people willing to share experiences. It is so hard to get useful information when a person is detransitioning or experiencing regret. We can’t disagree with people’s experiences even though as a society we would like to tell people their experience is wrong.

I wanted to talk about blogs that I follow when I can. I have a lot of respect for the people who are willing to publicly share their experiences. They often are criticized and attacked for doing so. I think gender therapists should be reading about the experiences of people for whom transitioning did not work or did not address the issues they thought it would when they transitioned.

These blogs can be upsetting, painful, in that they are real people who have had real experiences and have stopped transitioning or transitioned back. There are different ways that people frame this and some people feel they made a mistake and other people do not. Some of them feel they have been harmed by the medical and mental health establishment. I’d say they have. None of these folks is shirking their own individual responsibility, but some of them are raising genuine criticisms of therapists and medical providers and we need to listen to them. I think of regret in a variety of ways and one of them is that it is a complication of transitioning. Medical intervention is not the correct course for everyone with dysphoria. Many things should be discussed and considered to relieve dysphoria.

Crashchaoscats

Thoughts about living as different genders, taking t and stopping, how gender seems to function in this society and other related ideas that churn around in my brains.

This site is “pro people” and all about finding your correct path in life even if it involves a few wrong turns along the way. It also aims to further the understanding of transgender issues by discussing topics that fall out of the mainstream understanding of non-binary gender identity expressions and identity.

I’m a 23 year old woman with sex dysphoria, finding other ways to deal with this besides transition. I was diagnosed with GID, spent three years living as male, a year and a half on testosterone. I have been detransitioning for a year and a half.

This is a woman with interesting and I think important ideas. She is very clear about the distinction between sex dysphoria and gender dysphoria and doesn’t speak to gender dysphoria (except to share her political frame on it.) She has very useful information about coping with sex dysphoria. She also speaks to the pressure to transition, something I absolutely believe is a real experience for some people. She is also very critical of the process we use to assess and refer people for transition related care.

Redress alert
Another very important blog also focused on sex dysphoria. Very political, very thoughtful. Lots of good information about the experience of detransitioning, something we really need to provide to people.http://redressalert.tumblr.com/

In evaluating risk, people should consider a variety of different issues. Some of them are the same issues that anyone considering a surgery that is not an emergency surgery (an elective surgery) should be considering. In researching surgical outcomes, there is a whole literature about problems related to hospitalization.

Hospital Acquired Infections

A study was released this year in the New England Journal of Medicine that talks about prevalence of hospital acquired infections. They looked at 183 hospitals and 11,292 patients. MaGill, S. et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. N Engl J Med 2014; 370:1198-1208March 27, 2014DOI: 10.1056/NEJMoa1306801 http://www.nejm.org/doi/full/10.1056/NEJMoa1306801.

1 out of 25 people will get a hospital acquired infection. These are called HAIs or health care acquired infections or nosocomial infections. About half of these occur in intensive care. There were about 722,000 HAI’s reported in 2011 and 75,000 people with and HAI died while hospitalized. That does not mean they died from their HAI. Simply that when they died they had an HAI.

What kinds of Infections?
Pneumonia (21.8%) and surgical site infections (21.8%), gastrointestinal infections (17.1%), urinary tract infections, and blood stream infections make up the largest number of HAI. Devices such as central lines, catheters, intubation, etc. accounted for 25% of the infections. The major biological culprit was Clostridium difficile AKA C difficile.
………

Any surgery involves risk.

These include: infections, as stated above, bad reactions to medications including allergies, blood clots, necrosis, scarring, nerve damage, short term pain, and the development of chronic pain.

Plastic surgery can not guarantee outcomes. Disappointment is a big risk. Realistic expectations are important. Often people have results or scarring they did not expect. Sometimes that is the responsibility of the person having the surgery for not following the surgeons’ directives. People who do not follow directives or withhold information from surgeon’s are risking bad outcomes. For instance, people who think the requirement to stop smoking is simply a moral issues rather than a surgical outcome issue and resume smoking as soon as possible will likely reget that decision.

Medication interactions. This is very important for people on psychiatric medication. There are pain killers that can interact with SSRI’s and SNRI’s and cause serotonin syndrome. Make sure your surgeon knows what medications you are taking.

Hospitals

Look into your hospital. As an informed consumer, it’s worth researching your hospital and not just your surgeon.

People in hospitals make mistakes. The IOM says it’s about 98,000 people a year but a newer study suggests that hospital care is the third leading cause of death in the US.

That study estimate harm from patient care in the hospital and came out last year. That study was conducted by someone who lost their child and attributed that death to negligence. It’s worth reading and assessing for yourself. James, JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care Journal of Patient Safety: September 2013 – Volume 9 – Issue 3 – p 122–128

There is so much we do not know. That’s true of a lot of things. Consumers of healthcare and mental healthcare have to be their own advocate. Generally, health literacy in the US is quite poor and mostly inadequate for people making the decisions that they make. Only 12% of Americans would be considered to be literate in terms of their healthcare. 1

Most studies either leave out a lot of information or have some other problem(s) with them that raise questions. It’s easy to take the conclusions at face value only to discover there were flaws in the methodology or some other aspect of the study.

Testosterone has side effects that we know and likely ones we don’t know. We also know that for some people testosterone is life-saving. Knowing as much as a person can know ahead of time is important. There are risks and potential benefits. For some people the risks outweigh the benefits and for other people, the benefits far outweigh the risks. There are studies that come out in both directions about testosterone in cisgendered men and we have a handful of studies that say it is safe in transgender men.

There are two recent studies that seem important related to testosterone. (2) (3)
A meta analysis of over 8700 male veterans with low testosterone having coronary angiography where over 1200 started testosterone. (2) Risks for the no testosterone group was about 20% and 25.7 in those were were prescribed testosterone. The mean age was 60.6 years. These were older men with comorbid health problems. Only 13 of the 123 MIs or strokes were gel users but can’t really say much from that. Injected testosterone causes peaks and troughs unlike gels or cream.

No data on how the T was prescribed or used, no follow up monitoring of levels in over half of the studies; and the control group had higher levels of T than the group prescribed T. Who knows for how long they had lower t or what the impact of that was. Really, it’s not clear what the levels ultimately mean because the range in normal levels is vast. Finally, there was no information on estradiol levels. Bodies are complex systems. Interestingly, the human body converts testosterone into estrogen. At too high a level it is thought to cause heart attacks in people predisposed to heart disease and to cause clotting problems that can cause strokes. Aging men convert more exogenous T into estradiol. (4)

In the second one, men taking testosterone were significantly more likely to have a heart attack, a myocardial infarction, in the three months following starting on testosterone. (3)
The risk of MI was increased by 36% and for men over 65 the risk of MI was twice as high.
The study was a population of records for over 55,000 men in large healthcare database. These men were compared to over 167,000 men recently prescribed sildenafil (Viagra) or tadalafil (Cialis). Younger men with pre-existing heart disease and older men had a substantially great risk of a heart attack within 90 days of beginning treatment.

Studies in the past showed the testosterone had a protective effect(5) or testosterone balance that was balanced with estrogen was heart protective. (5a)

Other studies in the past showed the opposite. (6) Higher serum testosterone levels were associated with a reduced risk of fatal and non-fatal cardiovascular events in older men. Both high and low levels are associated with cardiac risk.

Many people feel the study is flawed and refer to is as junk science. This is not a randomized, placebo, double-blind study. Is it replicable. he study raises lots of questions about methodology etc. Why a control group of people on sildenefil?

To start, what kind of T? bio-identical or not? Dosage? Frequency? What was the method of delivery? Injectable, pill, gel, creme or patch? Were the men monitored by lab work and dosages adjusted or did they just a prescription and sent off? What was the level of T in those who had Is compared to those who did not? Pre and post T levels. What rationale for starting t in the first place. How about other risk factors for MI that we already know about? Exercise, race/ethnicity, SES…were the doctors trained to prescribe and monitor?

Generally T increases energy, people will do more including more sex and other vigorous activity. Viagra focuses on sexual activity, not other vigorous activity which is one of the reasons they chose it as a comparison.

Then is this data transferable to trans men and gender queer people? Who knows? Anyone stating an opinion is doing just that. There is so little that we know as fact.

There are multiple studies that state that T is safe for transmen long term.
(7)

Effects of T Assuming an individual wishes to transition:
(everyone’s body responds differently so these are general)

Varies by person whether it’s good or bad or neutral
reduced fertility-possible permanent loss of fertility
hirsutism, increase in facial and body hair, changes in texture of hair
changes in sexual orientation/preferences/behaviors
effects of mood-generally inhibits depression, some people feel more aggressive, many people feel more even, more stable
increased libido, most folks think this is good
redistribution of fat
lowered voice, change in larynx
skin changes, veins more prominent
increase in the size of the brain
increased appetite

There are MANY less common side effects but if you are one of the people who gets that side effect, it’s a real problem for you. These include peripheral edema, hypertension, erythrocytosis-increased clotting factor so can cause heat attack or strokes, abnormal liver enzymes, liver damage, sleep apnea-an person stops breathing during sleep, liver problems, endometrial hyperplasia-precursor to uterine cancer, uterine bleeding, headaches can worsen or develop,

Going off of T a starting list
Expect your moods to shift, your energy to decrease, your sex drive to decrease. Possible your entire sense of self changes and people may feel a loss and not like themselves. Testosterone is thought to decrease depression and keeps moods more even or enhanced in many people. We do not know what ultimately changes regarding mood and brain issues. We don’t know what is permanent in term of changes in cognitive style or accessing emotions.

At the time someone starts T, they generally believe it is going to be helpful. If an individual has come out as trans and goes off T there are many social issues that arise that are equal to or more significant than the physical changes from stopping T. (The trans community can be hostile or unaccepting of people who detransition. People can lose the community they created after losing their family or their previous community. It’s a multiplied loss. People can also feel as though they failed in their transition.)

4) Lakshman KM, Kaplan B, Travison TG, et al. The effects of injected testosterone dose and age on the conversion of testosterone to estradiol and dihydrotestosterone in young and older men. The Journal of clinical endocrinology and metabolism. Aug 2010;95(8):3955-3964.

5) Ohlsson C, Barrett-Connor E, Bhasin S, et al. High serum testosterone is associated with reduced risk of cardiovascular events in elderly men. Journal of the American College of Cardiology. Oct 11 2011;58(16):1674-1681.

Abstract
INTRODUCTION:
Sex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross-sex hormone therapy and sex reassignment surgery on sexual desire in trans persons.
AIM:
This study aims to explore associations between sex reassignment therapy (SRT) and sexual desire in a large cohort of trans persons.

RESULTS:
In retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy-three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it (P = 0.03). In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD (P = 0.02). Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD (P = 0.02).

Here in California, the DMHC said insurance companies must provide transition related care. This is an important step. And with it, it brings challenges. Increasing numbers of people will surgically transition and with those increasing numbers will come increasing numbers of people who detransition. The fact that access to surgical procedures has increased doesn’t mean that surgery is right for everyone. Anesthesia is an insult, an injury to the brain. I don’t know where I read or heard this but it takes a month to heal for each hour a person is under. Surgery is permanent, too. People cannot predict the aesthetic outcome. It could be good and it might be different than you were expecting.

Some general advice. Be sure to base your expectations on real bodies. Real bodies are imperfect. More importantly, it is important not to rush and yet that is exactly what happens for many people. Our system rushes people as well. Doctors spend 5 or 10 or 20 minutes with a patient-not much time at all. You deserve to take the time at each point and experience the changes that are happening and experience who you are at that moment. Hormones change your brain at the same time they are changing your body. Your social world changes, too. Your support system, friends and family are trying to catch up with you. Partners may think they can handle the transition only to discover they are not who they thought they were so they can not be who you need them to be. One of the biggest issues that people talk about with regret is loss. Loss of community, family, partners, religious communities. It may feel intellectually possible to tolerate a loss but for some people, until they live with that loss, they cannot know.

Sometimes expanding one’s social role, increasing comfort with gender expression, expanding the box of male or female and addressing misogyny or investigating the genderqueer, two-spirit, agender, bigender, is what helps. Some peoples gender dysphoria decreases enough with just the use of hormones. Some people’s gender dysphoria decreases after an orchiectomy so much so that further surgical intervention is unnecessary. One step at a time. People will have an idea about having everything at once-chest surgery and genital surgery. That can backfire.

Some people have what feels to them to be a birth defect that can only be improved through hormones and surgery. Some people just don’t feel stereotypically male or stereotypically female and we don’t have much tolerance for them in a polarized society. There is a range of people who experience gender dysphoria. There is no one size fits all. I know I say that a lot. But we like boxes and we like people to neatly fit under their lids. It’s disconcerting to our society when people are popping out of the boxes.

Make sure that your provider spends a lot of time and answer all of your questions. What the risks and benefits and what are the alternatives. You want the MD to know things you don’t know. That’s why they are the doctor and you’re the patient. But we know that many transgender, transsexual and gender non-conforming people have to educate their medical providers so you often cannot count on genuine information to provide the “informed” part of the consent. Find legitimate information.

Changing one’s gendered body is not like getting a tattoo. It’s not like getting pierced. It is a life long treatment with many psychological and physical implications. Even when a person wants hormonal, social and or surgical transitions, there is so much to know. And there is so little we know.

We have no tests, not really. What we have are clients who come in self-diagnosed and who say they know. And the truth is, people generally do know themselves so much better than anyone else. What is also true, is that there are things a person cannot see in themselves, that others can see. There are things they believe are connected to one thing and it turns out they are probably connected to something else in entirely, or that it’s overdetermined. Sometimes, we don’t really know how to put the puzzle pieces together until time passes.

Make sure you give yourself time. There is no rush, at least not in adults.

What research participants said:
The person was not transsexual, they were misdiagnosed, the real issue was not addressed, the person felt they needed to accept their body, had to accept social role/expressions.

They lost people in their lives, lost partners, lost children, were lonely

They were disappointed in the surgical outcome.

Passing was not possible.

They transitioned for someone else.

What therapists think are poor prognostic indicators:
Older age when transitioned
Someone who would be perceived as transgender, not as male or female
Heterosexual before transition
Mental health problems
Criminal record
Military service
Unrealistic expectations
Ambivalence towards surgery
Substance use
Self mutilation

Things I think right at this moment and I’m sure I’m forgetting something:
That before we accepted that people could be genderqueer or in between or neither, people who were those identities were forced to transition.

That people made the best guess at fixing what felt wrong with them at that particular moment and that as they lived and grew discovered it didn’t fix the problem. Sometimes living as the other gender gave folks new information with which to understand themselves.

That expectations are mismatched with reality and that too can be connected to poorly done informed consents. Genital surgery changes what is between one’s legs and will not make anyone accept someone or stop discrimination. I think very tall women and very short men suffer as well. Some therapists say to not address that, that in the old days people had to be passable to get surgery. I suspect it’s not an either or. It’s not whether I can live with the person being unusually tall or unusually short or having stereotypical features of their natal sex, it’s whether they can.

That informed consent is inadequate as it is actually done.

That surgical outcomes have vastly improved from when many of the studies were done.

That there is peer pressure to transition. That young people coming of age today come out into the queer community and not necessarily the gay, lesbian or bisexual communities. People have complained about a movie that a group of young people made about GLBT issues saying there was too much in it that was trans. That is looking at youth through a very old lens. We need new glasses. Young people today come out into the queer community which has trans youth. They also come out into a world where people explore body modification in a way that did not exist previously. They can pierce and tattoo and so taking the leap to sculpting with medical technology isn’t much of a hop.

My belief too is that the lesbian and gay communities have always abdicated responsibility for youth, partly because we have been struggling so much on our own. Partly because we are seen as child molesters who are recruiting youth. Partly, too, because we have never been a community but many micro-communities that are loosely in coalition. Lesbians spent the last two decade learning how to move through the world as parents and gay men have done the same thing the last decade or so. So youth today come out into a different world that is truly not supported much by adults at all.

Another component is that as a society we have medicalized so many problems. This DSM included grief. We have social problems that we have individualized and taken out of the social context.
We don’t resist as a group anymore. We take medication. Years ago people talked about how seeing therapists led to passivity. As a radical therapist, I didn’t buy that. In the same way as we explain what is happening in the brain when one has a psychotic break, we can talk about what happens in the brain when one is traumatized and abused, when one is limited by society or when society sets out to harm specific groups. I am guessing that I was wrong much the same way as any individual can behave one way and the group to whom they belong behaves in another way. As a profession, whether we want to or not, we’re becoming increasingly medicalized because of insurance and the standards of care that insurance companies endorse. But they endorse what they want to pay for and see what they want to see.

Some gender nonconforming people are inadequately diagnosed and that is on therapists and PCP’s but sometimes it is on individuals who intentionally won’t let us do our jobs because they expect we will limit, or harm or deny their identity or they see manipulating medical and mental health professionals as a radical act. People self diagnose a variety of medical conditions and go to their PCP who says, no, it’s actually this other condition. That happens here as well except that clients likely will reject a clinician saying it is real but may have another origin.

That issue is connected to bias and stigma about mental health. People in the US don’t take mental health seriously, and still see it as willful or malingering or exaggerating. It’s easy for people to self-diagnose when it comes to mental health related issues since it’s not like a medical disorder. If I see trauma and the person sees only their gender dysphoria, I will be perceived as a barrier and as denying the individual’s self-awareness or undermining their autonomy. Unlike medical doctors, what therapist do and know doesn’t count in a society that doesn’t respect mental health. We constantly compare gender to the gay liberation movement. Unlike being gay or lesbian, there really are other issues that can look like gender dysphoria and people who talk with friends or read on the internet about how to present to us to get what they believe they need are doing the best they can to fix something that is terribly wrong inside them but we all have to do a better job.

People who have identity issues, think about identity issues. Questioning doesn’t mean a person made the wrong decision. It doesn’t mean a person will make the right decision, either.

Wherever you are, you very likely will have days that you doubt or question yourself and any of the decisions you have made or are considering making. Gender is not seamless for anyone unless they are entirely gender conforming in every way or have a consolidated gender identity and even then it still may come up. This is especially true for people who question authority or have feminist political analyses. Questions are good. Doubt is important.

How do you know if you are really transgender? How will a therapist or a doctor? What is transgender, anyhow? That’s gotten very blurry. A person can be gender non-conforming and not be transgender. Other people might call them transgender and throw the person under the transgender umbrella. They could be transsexual, believing in the body brain mismatch, they could be someone who identifies as mostly male or mostly female or neither, they could be genderqueer, they could be a woman who prefers to do things associated with masculinity. Simply not feeling male or not feeling female doesn’t necessarily mean that a person should transition. Simply preferring to wear clothing that is associated with a sex different from one’s body doesn’t make a person trans. Fantasizing about yourself as the other sex doesn’t make you trans. We have a lot of blurriness around gender.

There is no lab test to see if a person is transgender nor is there a personality test. A therapist cannot tell you. A doctor cannot tell you. Only you can know. If someone else says they know this about you, they are likely not a safe person in some respect. A person knows themselves better than anyone else does. Many people would be more comfortable if it was not a subjective experience. There are risks and benefits and all change involves loss. It’s important to be as prepared for the loss as possible, but much of it cannot be anticipated. The losses people face are significant and for the right people, the gains are life-saving. Often people begin this process thinking they are transitioning to male, not transmale or female and not transfemale or genderqueer and not whatever the corollary would be. There is an image people have and it may not be the reality they reach.

There are people who transition and it is the best decision they ever made. There are people who are trans, but the emotional, social and identity costs of transitioning are simply too great. Perhaps, hormones didn’t fix what a person thought it was going to fix. Some people transition for reasons other than gender dysphoria and gender identity. Some people genuinely regret the decision they made to take hormones or have surgery and need to be supported in detransitioning. Detransitioning is also transition.

Some people start and stop their transition. They aren’t sure and need to go off hormones to learn something else about themselves. Or socially they can’t live as themselves and so they stop until they have the chance to start again in a manner that will work for them. They will lose too much at the moment so they stop. Some people detransition and it is not about regret, but rather they got where they wanted to get to physically or they discovered that it wasn’t where they wanted to go. Transition is not linear and is personal to each individual.

Transition is not a single event. How do one know what type of transition is right for them, if they decide that it is? (expression, community, social, legal, hormonal, surgical, etc.) Are they even thinking that way or are they headed straight for medical interventions?

In medicine and mental health we want to do what is least invasive first. When talking about gender non-conforming behaviors, we should not not immediately jump to surgery or hormones. For some clients or patients, they have been thinking about this for so long, and know it to their very core, any slow down is a barrier to getting their medical needs met. Other people are coming in with transitioning as just a first or second pass as an answer to their questions. Providers have to work with the person in front of us not what we expect. Sometimes, providers want to be experts and tell patients who they are before the patient or client decides who they are. It’s easy to fall into that trap. Providers want to help and in marginalized populations, people can reactively swing to being proactive rather than empowering.

We can draw a line between any two points—meaning that we have two facts that may or may not be connected. For instance, person A was sexually abused and person A is sexually attracted to people of the same sex. We can run with that and say sexual abuse causes same-sex attraction. People used to say that all the time. All we have are two points of information. These points are only <em>correlated</em> for <em>that</em> person, they are not necessarily causative or representational. Not much more can really be said about this.

We have two bits of information we are trying to make sense of. People are trying to make sense of their lives and their choices and make meaning from their experiences. Back to the sexual abuse and gay question. I imagine there are very few people who were sexually abused and then later came out as gay or lesbian or bisexual who have not wondered about the influence of that violation on their sexual orientation or sexual preference.

One of the political issues that arose from the fact that there were a disproportionate number of gay and lesbian people who had histories of abuse or sexual interactions with people who were older is that anti-gay people used it to say homosexuality was caused by abuse. In reaction, we had GLBQ folks begin to deny or not admit that they were abused because it would be used against the community.

In truth, there is a disproportionate amount of abuse, but the alternate explanation is that gender non-conforming children are different and may be isolated and predators choose kids who are different or isolated. Then there are the disturbed people who believe sexually assaulting an individual will teach them to be heterosexual. It is more likely that kids were targeted for gender non-conforming behaviors and we going to grow up to be GLBTQ rather than the outcome being homosexuality as the result of the assault. Another myth from the old days was about distant fathers of boys. Which came first? Having a gender non-conforming child that a 50’s father was ashamed of or disappointed in or disgusted by or the distance between the father and the child? Chances are insecure fathers created the distance because of the perceived gender non-conformity rather than the distance causing some sort of longing in the son that got sexualized.

We need to be careful about cause and effect, causation and correlation. We need to be careful about our explanations for behaviors and feelings. Person B says they hate their breasts and want to have them removed. For Person B it could be because they are trans, because they hate being sexualized, because they have neck and shoulder pain, because breasts are inconvenient, or because they interfere with activity. It could be all of the above. The real issue might be none of the above. Each person is a person and not on the same path as the next person over. There is no one true path and it’s not cookie-cutter. Many providers and patients would like for it to be. Patients want relief from suffering and clinicians want to help and provide answers. We’d all like to take the guesswork out of this.

Many people look back at their lives from whatever point they are standing at and try to find proof that they are who they feel they are now. Remember you can connect any two points. Lots of gender non-conforming kids behaved in gender non-conforming ways. So it’s easy to create a narrative of a long-standing transgender identity. Recently I was asked to give a gender history of person from childhood. It reaffirmed the ridiculousness of that question. I needed to talk about trucks and swim suits and other bricks in the narrative wall the client has constructed and make that palatable for the reviewer who is looking for binary expressions. It very much was “prove to me this person is actually a man or a woman.” I can’t do that. I can report what is said but I understand the context that narrative developed within.

We have so little research and much of what we have now and what we will have in the future will be biased anyhow. We have stories and narratives and anecdotes that we should take seriously and share.

Mostly what we have are people taking their best guess at why they don’t feel okay in their bodies or souls or hearts. Two people can have the same experience for different reasons and need to walk different paths. (I hate being a woman and woman is not me. 1) I hate being a woman because I am actually a man. Nothing about me feels right and certainly not feminine to me. 2) I hate being a woman because I hate the weakness, the self-deprecation, the vulnerability, the passivity of women. That’s not me and not the life I want.

These two people, one is transsexual and the other is expressing internalized and experienced misogyny. If transitioning the answer for them both, I would expect the second person to still not be comfortable in themselves and in the world. I have no research to prove this. Women are socialized to hate their bodies in America. Media influence is inescapable where beautiful women are airbrushed and photoshopped to be perfect and not exist in reality. We stereotype men and women. People who are moving from one side to the other in search of the stereotype will not likely find it in their transitioned body and mind. We are all socialized to be dissatisfied with ourselves and what we have in some way.

Suggestions:If you watch YouTube videos, you see a lot of newbies. People who have not yet lived in their transitioned gender for years yet. Read about people who transitioned ten or twenty years ago to get a sense of what life has been like for them. Be careful of writing people’s experiences off because they are older or a different generation. They are forefathers and foremothers and foregenderqueers.

Read blogs by people who have detransitioned or regret transitioning. You may not hear stories like these from your circle of friends or your providers. Remember, they exist in a context. Some people are very angry or feel harmed. They have important stories even if they say things that may feel invalidating or offensive. Listen for what is important and discard what doesn’t fit. We have to listen to everyone.

Understand that transitioning now exists in the context of now. Transgender people have been harmed and stigmatized and are are trying to prove that they are healthy and well-functioning and that transitioning should be accepted. Often you will hear so much positive that it drowns out the questions, the concerns, the negatives. Look for the questions, look for the downside, the things people wish they would have known. Go into this with your eyes open. People are looking for role models and heroes. Listening to people criticize or laud Chaz Bono should be instructive. He’s just a guy and makes decisions and mistakes like any other guy, but it’s in a community desperate for adequate representation.

If you have mental health issues like depression, a mood disorder like bipolar disorder, emotional reactivity related to a trauma history, get help for those issues. For a few people, those issues are connected to their gender identity. For most people they are not. They may be connected to gender discrimination or stigma but that is different.

Mental health and medical providers have to learn about and talk about detransition. We have to figure out what the medical needs and mental health needs are for folks who transition back. Many people simply leave health care, leave their hormone provider and detransition on their own. We don’t want people to transition on their own so we sure don’t want them to detransition on their own. Often people don’t see a therapist about this or at least not their gender therapist. If they had one. Sometimes this is because a therapist has become a cheerleader for transition rather than an objective support for the individual.

I believe that we have to provide support for detransitioners the same way that we provide support for transitioners. Continue reading →